2009_0427_Packet - Laserfiche WebLink

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Attachment A Cih� of . �� �► ;Vlinnesota. LI;�A EMPLOYEE NAME Benefits Plan Contribution Incentive Earn $10 a month toward your health insurance. Complete items A, B, and C below and submit a copy of this form with your benefits enrollment for the New Year. Note that the physical exam/screening (item A) is required on a schedule determined by your physician, whereas the blood pressure screening (item B) and Health Risk Assessment (item C) need to be completed at least once a year. A. Physical Exams/Screenings as appropriate for your gender, age, and personal risk factors as performed by a physician and/or other qualified medical professional are required at the intervals recommended for you by your physician. Sased on your physician's recommendation, a physical exam/screening might include blood sugar or cholesterol testing, colorectal cancer screening, mammogram, obesity screening, tobacco use/exposure screening, calcium/osteoporosis counseling, alcohol abuse screening, depression screening, cervical cancer screening/pap smear, and/or folic acid screening. Your physician's determination of wxicx exams/screenings you need will not be shared with Roseville Human Resources; H.R. only needs to know you have had a physical exam and wxEN your physician wants to see you again. This section is to be completed by employee's physician. Clinic Name/Address Stamped Here: Date of most recent wellness physical exam or screening: Next physical exam or screening should occur by the end of Physician's signature: ►:�►i �� Month and year B. A Blood Pressure Screening performed by a qualified medical professional is required every year. This screening can be a part of a visit to your physician, blood donation center, or the neighborhood fire station. Screener's Company Name, signature and date(s) to verify screening(s)